Download Augmentative and Alternative Communication (AAC) Assessment for

Augmentative and Alternative Communication (AAC) Assessment
for Philadelphia IDS Consumers
The Institute on Disabilities at Temple University is available to conduct Augmentative and
Alternative Communication (AAC) assessments, using qualified, licensed speech-language
pathologists (SLPs). Assessments may be completed for individuals with disabilities and
communication needs who are served by Philadelphia IDS.
Please note: This service is only available to Philadelphia IDS consumers aged 21+
As a result of this service, recommendations will be provided to individuals with disabilities, their
families, and other team members. Recommendations may include:

Strategies to increase opportunities for communication and increase the likelihood of
successful communication

Supports for the implementation of AAC strategies

Ways in which AAC may help establish functional communication
(including, but not limited to, speech-generating devices)

Identification of related assistive technologies (e.g. for telephone communication)

Assistance with acquiring AAC devices or other assistive technology devices and services.
To submit your request for Augmentative and Alternative Communication (AAC) assessment
Complete and return this form (along with relevant ISP pages) using fax, regular mail or via
an encrypted email/file sharing, such as https://tusafesend.temple.edu/
Kathryn Helland, MS, CCC-SLP
Augmentative Communication Services Coordinator
Encrypted: https://tusafesend.temple.edu/ Email: [email protected]
Fax: 215-204-6336 (Attn: Kathryn Helland)
Institute on Disabilities at Temple University
Attn: Kathryn Helland /1755 N 13th St, Student Center, Rm 411 S / Philadelphia, PA 19122
Please contact your agency’s Communication Champion or Kathryn Helland by e-mail
([email protected]) or phone (215-204-3032) if you have questions about this process.
Revised 1/2016
AUGMENTATIVE AND ALTERNATIVE COMMUNICATION
EVALUATION REQUEST
Philadelphia County IDS Consumers ONLY
Consumer’s Name
Birthdate:
GENERAL INFORMATION
Today’s date
Gender
Language(s) Spoken
 Male  Female
Street Address
Telephone
City, State, Zip
Email
Type of Residence  Family Home
Other________________
Residential Agency
 Community Living Arrangement

Contact’s Phone
Residential Contact
Contact’s Email
Supports Coordinator (SC)
SCO’s Phone
SCO/Agency
SCO’s Email
*All scheduling will be done through the SC. Please star the best way to reach the SC.
Revised 1/2016
PRESENT VOCATIONAL OR DAY PROGRAM SETTING
Work/Day Program Agency
Contact Person
Street Address
Contact’s Phone
City, State, Zip
Contact’s Email
Activities/Duties
Hours attended
Please attach a copy of all relevant pages of the ISP. ~ Include Plan Summary, Individual
Preference (Know & Do), Behavioral Support Plan (if applicable), and Functional Information
(Communication, Understanding Communication), etc.
Referral made by
Relationship to consumer
Reason for referral
Please check any that apply:
 Recent change in communication status
 Family or advocate request
 Needs updated evaluation
 Change in behavioral profile
 Recent transition
 Past history of device use (no longer used/
working)
Additional relevant information
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Medical Diagnosis/es
MEDICAL INFORMATION
Speech Diagnosis/es
Date of last Vision test/screen
Results
Date of last Hearing test/screen
Results
COMMUNICATION INFORMATION
Estimate the frequency of each communication method used
along with how frequent any prompts/cues are needed with it.
Please enter R (Regularly), S (Sometimes) or N (Never)
Frequency
COMPREHENSION
Responds to speakers
Understands what is said to him/her
Prompts/Cues Needed
Follows routine, 1-step directions
Follows simple, multi-step directions
Frequency
Please enter R (Regularly), S (Sometimes) or N (Never) then describe.
Frequency Frequency
EXPRESSION
with
with
How?/What?
Familiar
Unfamiliar (Please describe)
Listeners
Listeners
Makes needs and wants known
Initiates communication
Speaks in words, phrases or
sentences
How many words?
Speech is easily understood
(if applicable
Writes or types
Uses gestures to communicate
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Uses facial expressions, body
language or other behaviors
Uses a communication board/book
What?
Uses speech-generating
/communication device
Client can recognize (check all that apply):  objects  photos  pictures  line drawings
Make choices between  2 items  more than 2 items
 pictures
 activities
What does the client communicate about?
What are the most important communication needs at home?
What are the most important communication needs in the vocational/work setting?
What has already been tried to improve communication? And, how did it go?
What results/information do you hope to gain as a result of this consultation or evaluation?
What are the consumer’s favorite topics and activities?
Is there anything else I should know about your consumer?
Complete and return this form (with relevant ISP pages, as described above)
to Kathryn Helland or encrypted: https://tusafesend.temple.edu/
Email: [email protected]) or Fax (215-204-6336)
Revised 1/2016
Page 2 of 6